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Op-ed: The untimely death of the physical exam

Andrew Kesselman, MD

Dec 17, 2013

Andrew Kesselman, MD

Patient history and the physical have traditionally been the pillars of medical diagnosis, however, in modern day medicine, greater emphasis is being placed on early imaging, especially in the emergent setting. This paradigm switch comes at the expense of the clinical physical examination. The days of your doctor palpating your belly and using their stethoscope to listen to your heart and lungs may be coming to an end. More and more, physicians are relying less on these techniques and supplanting them with advanced medical imaging for aiding diagnosis. This does not mean all of this methodology will disappear, but rather could become much more focused in application.

I am reminded of an anecdotal story told to me by a colleague. As a fellow radiologist, he had asked one of the referring physicians if there were any additional pertinent physical exam findings for the case. The referring clinician’s response was surprising as he proceeded to state, “You are my physical exam.” This was an isolated instance and doesn’t reflect the norm, however it may serve as a glimpse of where medicine is headed when access to advancing imaging is so readily available.

As a radiologist, I assume the role of gatekeeper to advanced medical imaging, an important resource in the field of medicine. Yet with debate concerning overutilization, improper ordering practices and radiation risk, limiting the use of this resource has become paramount. Rationing of healthcare is inevitable and it is important to focus on areas where the value is highest, factoring in both cost and improvement in patient’s quality of life.

Not all advanced medical imaging is harmless. Radiation in the form of x-rays that patients receive from medical imaging is many times greater than background radiation. CTs represent a large portion of this increased radiation exposure in the general public. Development of radiation-induced cancers is a real risk with a prevalence that is hard to define. Overuse of this resource is not only costly but also dangerous to our future health. It is for this reason that it is so important that not only radiologists, but also clinicians and patients themselves fully understand the risks, benefits and alternative options available. It is also important to explore all options, like non-invasive imaging techniques that do not involve the use of x-rays, such as MRI and ultrasound.

Bringing imaging directly to the bedside is a way that I can see medical care changing in the future. An early example of this technique is with point of care ultrasound. With the recent advances in technology, small lightweight portable ultrasound machines are available at the size of the average smart phone. Although currently quite costly, these units allow clinicians to perform a quick assessment of vital organs to an extent not possible through classic physical examination. Are these the future stethoscopes? It is hard to say, however as this technology expands and grows, these types of units will certainly become more affordable and commonplace in clinical practice.

I am hopeful as a physician that the untimely death of the traditional physical exam will not be in vain. These advances in imaging will lead to better care, more prompt diagnosis and improved outcomes. Growth in the medical field is important and it is my role as a physician and radiologist is to make sure these resources are used not only appropriately but also responsibly.

About the author: Andrew Kesselman, MD, is a diagnostic radiology resident at SUNY Downstate Medical Center in Brooklyn, N.Y.